A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
Delayed gastric emptying
Pulmonary edema
An upper respiratory infection
Atelectasis
The Correct Answer is D
A. Delayed gastric emptying is not associated with decreased breath sounds in the lower lobes of the lungs. It is more commonly associated with gastrointestinal symptoms such as bloating and nausea.
B. While pulmonary edema can cause respiratory symptoms, such as crackles and wheezes, decreased breath sounds in the lower lobes are not typically indicative of pulmonary edema. Pulmonary edema is more commonly associated with fluid accumulation in the lungs, leading to crackles and other signs of fluid overload.
C. An upper respiratory infection primarily affects the upper airways, such as the nose and throat, and typically presents with symptoms such as nasal congestion, sore throat, and cough. It is not typically associated with decreased breath sounds in the lower lobes of the lungs.
D. Atelectasis refers to the collapse or closure of a part of the lung, leading to decreased air entry and breath sounds in the affected area. In a client who has been on bedrest for several days, atelectasis can occur due to reduced lung expansion and ventilation. Decreased breath sounds in the lower lobes are a common finding in atelectasis, especially when the condition affects the bases of the lungs, as gravitational forces can exacerbate the collapse of lung tissue in dependent areas. Therefore, this finding is most consistent with atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "The oral medication you will take after this IV will dissolve the clot": This statement is incorrect. While anticoagulants like warfarin or direct oral anticoagulants (DOACs) may be prescribed to prevent the formation of new clots or to treat existing clots, heparin, whether administered intravenously or subcutaneously, is not typically used to dissolve existing clots.
B. "A pharmacist is the person to answer that question": This response deflects the client's question and does not provide useful information. While pharmacists are knowledgeable about medications, nurses are responsible for educating clients about their treatments and should be able to provide accurate information regarding heparin therapy.
C. "Heparin does not dissolve clots. It stops new clots from forming": This is the correct response. Heparin is an anticoagulant medication that works by inhibiting the formation of new clots rather than dissolving existing ones. It does so by inhibiting the activity of clotting factors in the blood, thus preventing the clot from enlarging or new clots from forming.
D. "It usually takes heparin at least 2 to 3 days to reach a therapeutic blood level": While this statement provides information about the time required for heparin to achieve a therapeutic effect, it does not address the client's specific question about clot dissolution. Heparin's anticoagulant effects occur rapidly, but its primary action is prevention rather than dissolution of existing clots.
Correct Answer is D
Explanation
A. Inverted P wave: An inverted P wave may indicate atrial depolarization abnormalities but is not typically associated with hypokalemia. It can be seen in conditions such as atrial enlargement or atrial ischemia. However, in hypokalemia, the P wave may become flattened or have a decreased amplitude, but it is less likely to be inverted.
B. Wide QRS: A wide QRS complex may indicate conduction abnormalities or bundle branch blocks, but it is not specifically associated with hypokalemia. Wide QRS complexes are more commonly seen in conditions such as bundle branch blocks or electrolyte imbalances like hyperkalemia. Hypokalemia tends to cause a prolongation of the QT interval rather than widening of the QRS complex.
C. Elevated ST segment: An elevated ST segment is typically associated with myocardial injury or infarction, not hypokalemia. It can be indicative of conditions such as myocardial ischemia or pericarditis. In hypokalemia, ST segment changes are more likely to be flattened or depressed rather than elevated.
D. Abnormally prominent U wave: An abnormally prominent U wave is a classic EKG finding in hypokalemia. Hypokalemia prolongs the repolarization phase of the cardiac action potential, leading to the appearance of U waves following the T wave. These U waves can become more pronounced as potassium levels decrease. Therefore, an abnormally prominent U wave is a significant indicator of hypokalemia on an EKG, especially in a patient with prolonged vomiting, which can lead to potassium depletion. Thus, it is the most pertinent abnormality to interpret in this context.
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